Basic Information
| Provider Information | |||||||||
| NPI: | 1437717717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ MARTINEZ | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | PHD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 10TH ST E UNIT 3409 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077937146 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2426 W BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554111735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2019 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103T00000X | LP6636 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.